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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To completed by APPLICANT <br /> Business Name_.V , I �) Is 4 ) o Lic.Plate# <br /> Owner/Operator Name r uv n v�hA evO <br /> Business Mailing Address 2303 7,je iyr] bi <br /> City ,q� o(K (u� State C�A""Zip 520.6 Bus. Ph. r/o, 3U3 - 274kji, <br /> h- Yui`'l� � ,a —, hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin Aounty Envi mental Health Department (EHD) requirements. If the use of the <br /> commissary is disconti ed, t permit hol mustFailure to notify this office may result in permit <br /> revocation and - <br /> Signature / Date <br /> 2. To be com letqd-by COMMISSARY OWNER/OPERATOR <br /> Commissary Name L rap jQa.aP7_jqFA# aj 4 <br /> Address bme 2 O. g ►q rel Bus. Phone ;2O`1 - ?f_ 7 9� <br /> City _ rT_Zip 9. Owner/Operator Vx_ <br /> Check all appropriate services provided:W Wastewater disposal O 3-compartment sink Q(/Electrical hook-ups <br /> ®JSolid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot& Coldwater for cleaning ❑ Store refrigerated food [Potable water <br /> 13 Store dry food/supplies Overnight parking LSD'Vehicle wash <br /> I. <r hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> aEE <br /> all no' a EHD immediately. <br /> Date 7 Z <br /> the ENV HEALTH jurisdiction outside-of San;Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> j5MI d KdV/'eA.S �Jlh IPre2Ra / �rnil G)"^ <br />